Addressing health inequalities

Abstract

Adam Oliver and colleagues1Oliver A Healy A Le Grand J Addressing health inequalities.Lancet. 2002; 360: 565-567Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar question the current focus in health policy on reducing inequalities in health. Challenges to the prevailing consensus on issues of health policy are always welcome; however, Oliver and colleagues' initial premise, that health inequalities are exaggerated, is at variance with the everyday reality of suffering and death among poorer people relative to the better off. Moreover, their discussion of the ethical framework for policy development and the issue of opportunity costs is limited. The apparently trivial absolute differences in annual mortality rates between rich and poor clearly translate into substantial differences in life expectancy, quality of life, and disability-free life expectancy.2Kunst AE Groenhof F Mackenbach JP et al.for the EU Working Group on Socioeconomic Inequalities in HealthOccupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies.BMJ. 1998; 316: 1636-1642Crossref PubMed Google Scholar, 3Melzer D McWilliams B Brayne C Johnson T Bond J Socioeconomic status and the expectation of disability in old age: estimates for England.J Epidemiol Community Health. 2000; 54: 286-292Crossref PubMed Scopus (92) Google Scholar, 4Hemingway H Nicholson A Stafford M Roberts R Marmot M The impact of socioeconomic status on health functioning as assessed by the SF-36 questionnaire: the Whitehall II Study.Am J Public Health. 1997; 87: 1484-1490Crossref PubMed Scopus (226) Google Scholar For instance, in the UK, men aged 65·69 years in social classes I and II can expect on average nearly 14 years of life free of disability compared with 11·5 years for those in classes III—IV. Men in this age-group and social class can also expect fewer years of disability despite longer overall life expectancy.3Melzer D McWilliams B Brayne C Johnson T Bond J Socioeconomic status and the expectation of disability in old age: estimates for England.J Epidemiol Community Health. 2000; 54: 286-292Crossref PubMed Scopus (92) Google Scholar With more detailed and reliable measures of socioeconomic status (including measures over the life course) and health outcomes, we can detect even greater degrees of health inequality by social class.5Power C Matthews S Manor O Inequalities in self rated health in the 1958 birth cohort: lifetime social circumstances or social mobility?.BMJ. 1996; 313: 449-453Crossref PubMed Scopus (161) Google Scholar We all accept the need for a coherent ethical framework or theory of justice in addressing health inequalities. However, we must also consider our political philosophy or theory of society—a fundamental issue not explicitly addressed by Oliver and colleagues. For instance, their view that “many differences in health across socioeconomic groups would not always be seen as inequitable if we remember that people have informed choice over diet, alcohol consumption, levels of exercise, etc”, raises fundamental issues about the role of the individual and the state, and the balance between individual rights and choice and the need for social cohesion and solidarity. From my perspective, the notion of the rational citizen making informed choices about diet and other aspects of lifestyle provides an inadequate model for population health policy. A focus on inequalities provides an important and useful conceptual framework for tackling fundamental determinants of health, particularly those related to poverty, educational exclusion, and occupational and other environmental health issues. However, there are limitations to this approach and we must consider opportunity costs. There is a danger that in our efforts to define, understand, and address health inequalities, we defer the hard choices, specifically the need to tackle entrenched commercial vested interests inimical to health in the global economy. When political parties, governments, and health departments embrace the health inequalities agenda, we might suspect that it poses few threats to major vested interests in society. It is now accepted that we must confront the global tobacco industry to reduce the global burden of smoking related disease. We need to make similar choices in relation to other industries, such as the food and alcohol industries. A focus on health inequalities will not always be the most efficient way to achieve our objectives. Addressing health inequalitiesAuthors' reply Full-Text PDF